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The rivalry between the two clubs started at the very beginning of the twentieth century. Madrid Foot-Ball Club (founded 1902), the most powerful club in the Spanish capital, kept on making mergers and acquisitions of the best smaller clubs in the city, which subsequently disappeared. At the same time, Madrid FC also signed the best players from the clubs it did not absorb, which also made those clubs defunct when they were unable to compete against the Whites. The main exception to this pattern was Athletic Club Madrid (founded 1903), who were able to keep most of their best players thanks to the financial aid of their "parent", Athletic Club Bilbao, and so became the last stand against the Madrid FC supremacy in the capital. Many supporters of the clubs that had vanished due to The Real (a recognition given by the King of Spain to his favoured clubs, bestowed upon Madrid FC in 1920) therefore became supporters of the Red-and-whites, many harbouring dislike towards the meringue club and triggering the rivalry.[2] However, regarding competitive honours won, Real Madrid were far above Athletic Madrid (who remained so named even after their separation from the original Basque club) until after the Spanish Civil War.

After the war, during the early Francoist period, Atlético became associated with the military air force, although the alleged preference of the regime for the club is subject to discussion (nonetheless, after winning their very first League title in 1939, Atlético coach Ricardo Zamora was put into jail accused of being communist). In any case, during this period Atlético became the most successful club in Spain, reducing the historical gap between the two clubs, until the regime preference shifted towards Real Madrid in the 1950s as Franco sought to make political capital out of Real Madrid's multiple European Cup titles at a time when Spain was internationally isolated; one minister said, "Real Madrid are the best ambassadors we've ever had." Thus, Atlético fans regularly chanted that Real were "El equipo del gobierno, la vergüenza del país" – "The team of the government, the shame of the country" – and allegedly adopted a more left-wing slant (tempered by the rise of ultras culture, and Rayo Vallecano's presence as the "true" leftist club in Madrid).

In the 1970s, Atlético took again the lead as the most successful Spanish club of the decade, which prompted the Real Madrid fanbase to look down on Atlético calling them and their supporters "Indios" (Indians, a reference to the Latin American players signed by the Red-and-whites).[3] It is worth noting that by then, Real Madrid was not very keen on signing non-Caucasian players (president Santiago Bernabéu even stated, when he decided not to sign Portuguese star Eusebio at the end of the 1960s, "Mientras yo viva, aquí no jugará ningún negro ni un blanco con bigote" ("As long as I live, no black or white with a mustache will play here").[4] Atlético's supporters accepted the new "Indian" nickname joyfully and have been using it until today.

In the modern era, the Madrid derby is the second biggest derby in Spanish football, behind El Clásico, and although Real Madrid have the larger worldwide fanbase, Atlético Madrid have also amassed a significant worldwide support, due to their level of success in the UEFA Champions League and UEFA Europa League in the early 21st century. Real Madrid is the most successful club in the Champions League, having won it thirteen times. Atlético have never won the Champions League, though they have reached the final on three occasions (losing narrowly to Real Madrid in two of those), and they have also won the Europa League three times since 2010 (compared to two UEFA Cups for Real Madrid in the 1980s) and the UEFA Super Cup three times (one of them against Real Madrid).

In domestic cups, the two have been finalists on five occasions in the Copa del Rey in 1960, 1961, 1992, 2013 (all Atlético wins) and 1975 (Real Madrid win). In 1985, they met in the two-legged final of the Copa de la Liga with each winning their home leg, although Real Madrid winning on aggregate. In 2014, they met in the two-legged final of the Supercopa de España: the first leg, at the Santiago Bernabéu, finished in a 1–1 draw, while the second leg, at the Vicente Calderón, ended in a 1–0 Atlético victory. With a 2–1 aggregate score, the rojiblancos won the title.

The two clubs met in the semi-finals of the 1958–59 European Cup. Atlético had qualified as La Liga runners-up; as Spanish Champions, Madrid, had already qualified as European Cup holders. The tie finished 2–2 on aggregate, and Real Madrid winning the play off game held in Zaragoza. Real then went on to win the trophy outright.

The two clubs met in Lisbon for the 2014 Champions League Final, making it the first time two clubs from the same city played in the final. Real Madrid won 4–1 after extra time, earning their tenth European Cup after having last won in 2002. They met again in the quarter-finals of the 2014–15 UEFA Champions League. The score was 0–0 at the Vicente Calderón and 1–0 in favour of Real Madrid at the Santiago Bernabéu.

As of 29 September 2018, the top scorer of all time in the Madrid Derby is Cristiano Ronaldo with 22 goals scored. The top scorer for Atlético in the derby matches is Paco Campos, with 12 goals.[13] Players in bold are still active.

The players with the most appearances in the Madrid Derby are Francisco Gento and Manolo Sanchís of Real Madrid, with 42 appearances. The record of most appearances in the derby matches as an Atlético player is held by Adelardo with 35 matches in all competitions and eight goals scored.